Request for Verification of Employment
Privacy Act Notice: This information is to be used by the agency collecting it or its assignees in determining whether you qualify as a prospective mortgagor under its program. It will
not be disclosed outside the agency except as required and permitted by law. You do not have to provide this information, but if you do not your application for approval as a prospec-
tive mortgagor or borrower may be delayed or rejected. The information requested in this form is authorized by Title 38, USC, Chapter 37 (if VA); by 12 USC, Section 1701 et. seq. (if
HUD/FHA); by 42 USC, Section 1452b (if HUD/CPD); and Title 42 USC, 1471 et. seq., or 7 USC, 1921 et. seq. (if USDA/FmHA).
Instructions: Lender - Complete items 1 through 7. Have applicant complete item 8. Forward directly to employer named in item 1.
Employer - Please complete either Part II or Part III as applicable. Complete Part IV and return directly to lender named in item 2.
The form is to be transmitted directly to the lender and is not to be transmitted through the applicant or any other party.
Part I - Request
1. To (Name and address of employer)
2. From (Name and address of lender)
Alejandro Rosalez
Carlos Salazar
123 Any Street, Any Town, USA
100 Main Street, Anytown, USA
I certify that this verification has been sent directly to the employer and has not passed through the hands of the applicant or any other interested party.
3. Signature of Lender
4. Title
5. Date
6. Lender's Number
(Optional)
Carlos Salazar
Project Manager
12/12/2006
5555-5555-5555
I have applied for a mortgage loan and stated that I am now or was formerly employed by you. My signature below authorizes verification of this information.
7. Name and Address of Applicant (include employee or badge number)
8. Signature of Applicant
Paulo Santos
123 Any Street, Any Town, USA
Paulo Santos
Part II - Verification of Present Employment
9. Applicant's Date of Employment
10. Present Position
11. Probability of Continued Employment
06/06/2006
General Manager
3 years
12A. Current Gross Base Pay (Enter Amount and Check Period)
13. For Military Personnel Only
14. If Overtime or Bonus is Applicable,
Annual
Hourly
Pay Grade
10
Is Its Continuance Likely?
Monthly
Other (Specify)
Type
Monthly Amount
Overtime
Yes
No
$ 5600
Bonus
Yes
No
Weekly
Base Pay
$
520
12B. Gross Earnings
15. If paid hourly - average hours per
week
Type
Year To Date
Past Year
Past Year
Rations
$
162
40 hours
Thru
2006
16. Date of applicant's next pay increase
30.00
Flight or
Base Pay
$
$ 20.00
$
Hazard
$
756
15.00
08/08/2007
Clothing
$
452
Overtime
$
15.00
30.00
$ 20.00
$
17. Projected amount of next pay increase
Quarters
$
986
$ 5600
Commissions
$
20.00
$ 20.00
$
15.00
Pro Pay
$
123
18. Date of applicant's last pay increase
09/08/2006
Overseas or
Bonus
$
20.00
$
20.00
$
15.00
Combat
$
645
19. Amount of last pay increase
Variable Housing
90.00
$ 4800
Total
$ 70.00
$ 80.00
$
Allowance
$
587
20. Remarks (If employee was off work for any length of time, please indicate time period and reason)
Not Applicable
Part III - Verification of Previous Employment
21. Date Hired
04/04/2004
23. Salary/Wage at Termination Per (Year) (Month) (Week)
01/03/2005
Base
$ 9500
Overtime
1250
Commissions
4500
22. Date Terminated
Bonus
4000
24. Reason for Leaving
25. Position Held
Medical Issue
Device Operator
Part IV - Authorized Signature - Federal statutes provide severe penalties for any fraud, intentional misrepresentation, or criminal connivance
or conspiracy purposed to influence the issuance of any guaranty or insurance by the VA Secretary, the U.S.D.A., FmHA/FHA Commissioner, or
the HUD/CPD Assistant Secretary.
26. Signature of Employer
27. Title (Please print or type)
28. Date
Richard Roe
VA Secretary
01/05/2007
29. Print or type name signed in Item 26
30. Phone No.
Richard Roe
555-0100
Form 1005
July 96